A recent study concluding that media coverage of managed care has been "largely neutral" has left many in the industry wondering if the parade of horror stories was just a bad dream.
In what the sponsors are billing as "the most comprehensive study to date of media coverage of managed care this decade," the Kaiser Family Foundation and Princeton Survey Research Associates found that "across all media types -- daily newspapers, business press and network television -- two-thirds (64%) of the stories" reviewed from 1990 to mid-1997 "took neither a positive nor negative tone toward managed care."
The Kaiser Foundation, based in Menlo Park, Calif., is an independent healthcare philanthropy not associated with Kaiser Permanente. Princeton (N.J.) Survey Research Associates is not affiliated with Princeton University.
The study, which analyzed a variety of national and regional publications and major broadcast news stories, was published in the January/February issue of Health Affairs. Its content analysis methodology counted the number of positive and negative "comments, interpretations and innuendoes" in a story, giving headlines double weight. If a story had at least a 2-to-1 ratio of negative comments, it was coded negative; a 2-to-1 ratio of positive comments rated it positive. A ratio of less than 2-to-1 either way meant the story was scored as neutral.
Although most of the media they reviewed were rated neutral, researchers found "managed care was most likely to be criticized in special series that appeared in daily newspapers (79% of coverage was critical, 20% neutral and 1% positive) and on network television newscasts (55% critical, 26% neutral and 19% positive).
The study also found the tone of coverage has become more critical over time and "is most distinguished by its use of dramatic anecdotes, villains and victims to vividly portray the story."
Mollyann Brodie, senior researcher and director of special projects at the Kaiser Foundation and one of the study's authors, says it was undertaken because "how the media has covered managed care has been debated constantly, without lots of evidence. We tried to produce data to try to shed light on the debate.
"Conventional wisdom said managed care has been bashed in the media," Brodie says. "In many ways, the data confirm that, since coverage has shifted to being decidedly more negative" over time. At the end of the period studied, 28% was negative and only 4% was positive, she says.
Besides, just because a story was coded neutral "doesn't mean it doesn't say negative things," Brodie says. "We're not claiming readers of the story didn't come away with a negative impression."
On the other hand, she says "there's evidence for both sides" of the debate, since over the entire time period the data show that coverage has been neutral.
"You can't think of the media as one Goliath. Some media have been bashing managed care, and others haven't," Brodie adds.
Susan Pisano, director of communications at the American Association of Health Plans, which represents HMOs and PPOs, says "those forms (of media) that are negative are among the most highly visible."
She says the challenge for the media now is to "look at what's in the bills" that are being proposed as consumer protection "and ask what the impact will be on people." Reporters are often surprised to find "how much there is in the way of provider protection" in bills put forward as consumer protection, she says.
As for the conclusion that most coverage has been neutral, she says, "if you look at the standard for judging, I'd be hard pressed to disagree with that."
Other industry sources were less agreeable. Counting negative and positive comments is not the way the average reader responds to a story, says Margaret Smith, president of Farwell Associates, a Los Angeles-based healthcare consulting firm that works with physicians in network development.
Because the topic in a story about managed care is generally about a patient who has been denied care or about some other difficulty with a health plan, "the impression that any breathing reader would get is negative," she says.
The idea that managed care is working well for most enrollees "hardly ever comes through," she says.
Jim Harris, director of public relations for Cigna HealthCare of California, has conducted content analysis before. Harris, who has a master's degree in mass communications, says Kaiser Foundation's methodology doesn't consider where the negative and positive comments are placed within a story.
"In many stories about managed care, the story starts out with a dramatic anecdote critical of managed care. At the end of the story, often on the jump page, is an explanatory quote from a managed-care executive to balance the story," he says. "But many readers don't get that far. They just see the anecdote at the top of the story."
Brodie acknowledges if readers don't get through the entire story, they often would come away with a negative impression. But she argued that researchers "looked at the context of the whole story." If comments at the beginning were overwhelmingly negative, the comments at the end had to be strongly positive in order to yield a neutral coding.
Another problem with the Kaiser survey, according to Harris, is its handling of broadcast stories.
"TV stories (in the study) are coded based on their script or narration," without considering the impact of the visuals, Harris says. They're often negative in impact and highly emotional -- a mother holding a critically ill baby, for example, he says.
Brodie says even though visuals weren't coded in the stories studied, broadcast news stories came out 55% negative anyway.
It's the images and anecdotes -- usually the "horror stories" -- that stick in people's minds, Harris says, no matter how many comments were positive or neutral.
In fact, in an earlier Kaiser Foundation study, researchers found "people seem to generalize from anecdotal reports in the news about problems with managed care." For example, two-thirds of respondents to the earlier study believed HMOs often or sometimes hold back on a child's cancer treatment (Nov. 10, 1997, p. 33).
"Any objective industry analyst will tell you that is preposterous, yet that is what the American public now believes, based upon media coverage," Harris says.
Another example of the bad media image the managed-care industry is enduring is a survey conducted last fall. The survey of Californians commissioned by a special task force on managed care reporting to Gov. Pete Wilson found 42% said they encountered a problem with their health insurance. "The media were quick to distort this" into significant problems with managed care, says Alain Enthoven, who chaired the task force.
Enthoven, a Stanford University professor and managed-care believer, says "many, but far from all, of the problems people reported . . . were generic to health insurance" and unrelated to managed care. "Of the 43% who said they were satisfied, 40% said they had a problem, so the `problems' could not all be too serious," he says.